India has had a sharp increase in the estimated number of HIV
infections, from a few thousand in the early 1990s to a working
estimate of about 4 million adults and children living with HIV/AIDS
in 2001. With a population of one billion, the HIV epidemics in India
will have a major impact on the overall spread of HIV in Asia and the
Pacific and indeed worldwide. Most of the Indian states have a
population greater than a majority of the countries in Africa.

The spread of HIV within the country is as diverse as the societal
patterns between its different regions, states and metropolitan areas.
In fact, India's epidemic is made up of a number of epidemics, and in
some places they occur within the same state. The epidemics vary from
states with mainly heterosexual transmission of HIV, to some states
where injecting drug use is the main route of HIV transmission. Both
tracking the epidemic and implementing effective programs poses a
serious challenge to the authorities and communities in India.

The History of AIDS and HIV prevention in India

When the first case of HIV was discovered in Chennai in 1986, the
Indian Government responded to the HIV epidemic immediately.
Recognizing the seriousness of the situation, the Government
constituted a high powered committee under the Ministry of Health and
Welfare. Subsequently, a National AIDS Control Program was launched in
1987. The program activities covered surveillance, screening blood and
blood products and health education.

In 1990, HIV levels were high amongst high-risk groups such as sex
workers and STD attendants in Maharashtra and injecting drug users in
Manipur; infection rates reached over 5%. This period saw the
beginning of a largely research-based national program. Surveillance
activities were launched in 55 cities in three states. The program
activities were left to the states and did not have strong central
guidance.

The National AIDS Control Organization (NACO) was established in 1992.
NACO carries out India's National AIDS Program, which includes the
formulation of policy, prevention and control program. The same year
that NACO was established, the Government launched a Five -Year
Strategic Plan for HIV/AIDS prevention under the National AIDS Control
Project. The Project established the administrative and technical
basis for program management and also set up State AIDS bodies in 25
states and 7 union territories. The Project was able to make a number
of important improvements in HIV prevention such as improving blood
safety. To strengthen surveillance the Government established 140
centers and 180 sentinel sites across the country, to monitor HIV
trends and the geographical spread of HIV among the general population
at-risk groups.

When surveillance systems in the Indian state of Tamil Nadu, home to
some 60 million people, showed that HIV infection rates among pregnant
women were rising, tripling to 1.25% between 1995 and 1997, the State
Government acted decisively. It set up an AIDS society, which worked
closely with non-governmental organizations (NGOs) and other partners
to develop an active AIDS prevention campaign. This included hiring a
leading international advertising agency to promote condom use for
risky sex in a humorous way, without offending the many people who do
not engage in risky behavior. The campaign also attacked the ignorance
and stigma associated with HIV infection, encouraging compassion for
those affected. The bold safe-sex campaign was a hit with its target
market of young sexually active men. Regular behavior surveillance
shows that the number of visits to sex workers and sex with other
irregular partners has fallen, and condom use during risky sexual
encounters has rise dramatically.

The Situation Now

Although HIV prevalence rate is low (0.7%), the overall number of
people with HIV infection is high according to estimates by UNAIDS.
The official Indian figures do not reveal such a scale of infection,
but weaknesses in the sero surveillance system, bias in targeting
groups for testing, and the lack of availability of testing services
in several parts of the country suggest a significant element of
underreporting. Given India's large population, a mere 0.1 percent
increase in the prevalence rate would increase the number of adults
living with HIV/AIDS by over half a million people.

HIV infection in India is currently concentrated among poor,
marginalized groups, including commercial sex workers, truck drivers,
and migrant labourers, men who have sex with men and injecting drug
users. Transmission of HIV within and from these groups drives the
epidemic, but the infection is spreading rapidly to the general
community. The epidemic continues to shift towards women and young
people with about 25 % of all HIV infections occurring in women. This
also adds to mother to child HIV transmission and pediatric HIV.

About 90% of the total reported AIDS cases occur in the sexually
active and economically productive 15 to 44 age group. Men account for
79% of HIV infections in India. The predominant mode of HIV
transmission is through heterosexual contact, the second most common
mode being injecting drug use. Previously blood transfusion and blood
product transfusion were also major causes, but blood safety measures
are now in place to prevent such transmission.

In 2001, the HIV infection rate went above one per cent in six states,
and the Prime Minister urged the Chief Ministers to intensify
prevention activities. Three states, (Maharashtra, Tamil Nadu and
Manipur), account for 75% of the country's estimated HIV cases. The
burden of AIDS cases is beginning to be felt in states affected early.
Mumbai and Manipur have recorded 20 to 49 per cent bed occupancy by
HIV positive people in certain hospitals.

In the most affected state of Maharashtra, HIV has reached 60% in
Mumbai's (Bombay) sex workers, 14-16% in sentinel STD clinics, and
over 2% among women attending anti-natal clinics. The prevalence rate
in women attending antenatal clinics can be treated as an indicator
for the prevalence in general population. This prevalence rate has
reached 6.5% in Namakkai in Tamil Nadu and 5.3% in Churachandpur in
Manipur.

The last four years have seen a broadening of the epidemic across the
southern and western states of India, as well a concentration of HIV
among the injecting drug users in the North Eastern states. The sharp
increases in Andhra Pradesh and Karnataka reveal that these two states
have overtaken Tamil Nadu as states with the highest prevalence rates.
In other parts of the country, the overall levels are still low with
some areas reporting no cases at all.

The AIDS epidemic in India consists of a number of local epidemics.
Around 70% of India's population lives in rural areas, once though to
be relatively immune to the epidemic. Some recent studies, however,
suggest that HIV has begun to spread in several rural areas. The
epidemic is now moving beyond its initial focus among sex workers and
injecting drug users and is shifting towards the general population;
making women and young people the most vulnerable for HIV infection.

In India, as elsewhere, AIDS is perceived as a disease of "others" -
of people living on the margins of society, whose lifestyles are
considered 'perverted' and 'sinful'. Discrimination, stigmatization
and denial (DSD) are the expected outcomes of such values, affecting
life in families, communities, workplaces, schools and health care
settings. Because of HIV/AIDS related DSD, appropriate policies and
models of good practice remain underdeveloped. People living with HIV
and AIDS continue to be burdened by poor care and inadequate services,
whilst those with the power to help do little to make the situation
better.

In a recent study by UNAIDS different levels of discrimination and
stigmatization were found among people living with HIV/AIDS in India.
UNAIDS found that there was uncertainty among health care staff about
basic HIV-transmission information and about the need for precautions.
Also, the study revealed a depressing picture of widespread labeling
and stereotyping and a lack of care throughout the health sector, with
the possible exception of a small number of hospitals where good
practice and policies have been established.

UNAIDS also found that HIV/AIDS related DSD in India is in some
respects a gendered phenomena. Women are often blamed by their parents
and in-laws for infecting their husbands, or for not controlling their
partners urges to have sex with other women. Children of HIV-positive
parents, whether positive or negative themselves, are often denied the
right to go to school or are separated from other children. People in
marginalized groups (female sex workers, hijras (transgendered) and
gay men) are often stigmatized in India on the grounds of not only HIV
status but also being members of socially excluded group.

The Future

For India to respond effectively to infection trends and limit the
costly social and economic impact of HIV and AIDS, its efforts need to
be accelerated, intensified and expanded while the country remains at
a low prevalence of HIV and there is still time to slow the spread of
the epidemic. With HIV prevalence doubling every one to two years in
certain groups, there is still a narrow window of opportunity over the
next few years in which to prevent the HIV epidemic from becoming
generalized and much harder to control.

India's socio-economic status, traditional social ills, cultural myths
on sex and sexuality and a huge population of marginalized people make
it extremely vulnerable to the HIV/AIDS epidemic. In fact, the
epidemic has become the most serious public health problem faced by
the country since the Independence.

The Indian Government and individual state Governments have launched
prevention programs to reduce high-risk sex and, there is evidence
that in some states these programs are resulting in safer behavior.
There are some success stories for effective prevention and control of
HIV infection. An intervention program among commercial sex workers in
Sonagachi, Calcutta has been able to increase condom use from 0% in
1992 to more than 70% in 1992-1994 and sustained this at over 70%
until 1998. If current prevention efforts can be scaled up and
sustained, India may be able to bring down the rates of HIV infection
in particularly exposed groups and avert a widespread heterosexual
epidemic.